ICP Flashcards
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?
a. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
b. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
c. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
d. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
b.
(A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.)
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?
a. blowing the nose
b. isometric exercises
c. coughing vigorously
d. exhaling during repositioning
d.
(Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva’s maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.)
Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 154/68, pulse 56, respirations 12
b. Blood pressure 134/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushings triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.
ANS: C
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patients neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.
ANS: B
Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.
A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?
a. Administer IV 5% hypertonic saline.
b. Draw blood for arterial blood gases (ABGs).
c. Send patient for computed tomography (CT).
d. Administer acetaminophen (Tylenol) 650 mg orally.
ANS: A
The patients low sodium indicates that hyponatremia may be causing the cerebral edema. The nurses first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
a. The staff nurse assesses neurologic status every hour.
b. The staff nurse elevates the head of the bed to 30 degrees.
c. The staff nurse suctions the patient routinely every 2 hours.
d. The staff nurse administers an analgesic before turning the patient.
ANS: C
Suctioning increases intracranial pressure, and should only be done when the patients respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.
A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?
a.
Coordinate the transfer of the patient to the operating room.
b.
Provide discharge instructions about monitoring neurologic status.
c.
Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
d.
Arrange to admit the patient to the neurologic unit for observation for 24 hours.
ANS: B
A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion.
While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patients nose. Which of these admission orders should the nurse question?
a.
Insert nasogastric tube.
b.
Turn patient every 2 hours.
c.
Keep the head of bed elevated.
d.
Apply cold packs for facial bruising.
ANS: A
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.
Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?
a.
Muscle resistance
b.
Short-term memory
c.
Glasgow coma scale
d.
Pupil reaction to light
ANS: B
Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.
When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find
a.
judgment changes.
b.
expressive aphasia.
c.
right-sided weakness.
d.
difficulty swallowing.
ANS: A
The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.
Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?
a.
I will return if I feel dizzy or nauseated.
b.
I am going to drive home and go to bed.
c.
I do not even remember being in an accident.
d.
I can take acetaminophen (Tylenol) for my headache.
ANS: B
Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.
After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to
a.
position the bed flat and log roll the patient.
b.
cluster nursing activities to allow longer rest periods.
c.
turn and reposition the patient side to side every 2 hours.
d.
perform range-of-motion (ROM) exercises every 4 hours.
ANS: D
ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
a.
Elevate the head of the patients bed to 60 degrees.
b.
Document the BP and ICP in the patients record.
c.
Report the BP and ICP to the health care provider.
d.
Continue to monitor the patients vital signs and ICP.
ANS: C
The patients cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patients therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.
After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?
a.
Document the increase in intracranial pressure.
b.
Assure that the patients neck is not in a flexed position.
c.
Notify the health care provider about the change in pressure.
d.
Increase the rate of the prescribed propofol (Diprovan) infusion.
ANS: B
Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure.
